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Rachel Hewitt plays the ball during a home game against Hill-Murray in September, 2016. Bulletin file photo.1 / 3

Rachel Hewitt's right knee. Youssef Rddad/ RiverTown Multimedia2 / 3

Christie Carli of Hudson is greeted by teammates during her first game back after suffering her second ACL tear in high school. Submitted photo3 / 3

A routine play turned into moments of pain and a year of recovery for Rachel Hewitt.

While 20 minutes into a soccer match, the Cottage Grove midfielder was attempting to cross a ball to teammates gathered near the goal. It was a play she had made hundreds of times.

As she kicked, an opposing player attempting to break up the play collided with her, kicking through Hewitt's leg as it hung in the air.

She said she felt a snap and started screaming as she fell to the ground.

"I went into shock kind of because I didn't know what was going on," Hewitt said. "I'd never heard of an ACL before then."

Without knowing at the time, she had joined the growing number of girls who suffer tears to the anterior cruciate ligament in their knee.

The steady increase of ACL injuries among high school athletes has some trainers and sports medicine professionals raising concerns about the prevalence of the painful knee injury. They say the higher level of play and competition, as well as pressures to play one sport in high school, are among the factors driving new injuries.

ACL tears often occur in basketball, soccer and football because they involve frequent pivots, shifts and jumps, which put added strain on players' knees. Several studies suggest girls are anywhere between three to eight times more likely to suffer an ACL tear than boys.

Unlike Hewitt's injury, many ACL tears don't involve hard contact, and injuries are more common during abrupt changes in momentum, for example, which cause the ligament to snap.

After noticing more patients at younger ages undergoing ACL surgeries in his practice, University of Minnesota orthopedic surgery professor Dr. Mark Tompkins said he wanted to find out if his observations were part of a larger trend.

A study he co-authored with other university researchers this spring in the journal Pediatrics found the rate of ACL injuries among girls had shot up by about 50 percent between 1994 and 2014, a 2.5 percent yearly increase over 20 years.

Researchers found high school-age girls accounted for the highest number of injuries by mining insurance data from HealthPartners. The insurer covers much of the upper Midwest, including all of Minnesota and much of western Wisconsin.

The study also highlighted wide disparities in ACL injuries between boys and girls.

In 2011, ACL injuries swelled to a rate of 181 injuries per 100,000 girls compared to 118 per 100,000 boys, the widest gap the study notes.

Sports doctors believe the higher rate of injury is partly due to development changes in the hips and muscular imbalances between the hamstrings and quadriceps put more strain on girls' knees than boys'.

Researchers also found older boys had a higher rate of injuries than girls. Tomkins speculated the greater rates in 17- to 18-year-old boys may be a result of more contact plays resulting in knee injuries.

A focus on prevention

Tompkins said his hopes for the study are to raise awareness to ACL injuries and promote prevention programs by providing raw numbers.

Some high schools already have turned their focus to such programs.

Scott Meier, a strength and conditioning coach at Farmington High School, said he's seen some improvement in reducing the number of ACL injuries.

The training the school uses aims to lower the risk of ACL tears by re-training how girls and when they jump, for example. In the weight room, trainers also work on developing the muscles needed to help athletes when they abruptly stop.

"When you don't have that strength to slow down and stop, that's when things start to tear," Meier said. "Physically, your muscle can't handle the stress."

Dubbed the "PEP Program," the training includes a mix of stretches and drills. Athletic trainers have touted the program, saying it teaches better habits for knee stability, especially when performing motions such as jumping, landing and pivoting that add stress to the knee.

Aside from reducing the chances of an ACL injury, the program can enhance an athlete's ability to jump higher and run with greater efficiency, said Steph Fall, a former trainer at New Richmond High School.

She hadn't noticed many injuries until her final year when she said about four to six student athletes tore their ACL, the majority of whom were girls and none was the result of a rough play.

"That was kind of a red flag," she said.

When looking at guarding against knee injuries, Fall said she would check girls' strength in the surrounding muscles, such as the hamstrings, core and hips.

"A lot of times it's not so much the ACL that's the problem, it's what's going on above and below," she said.

Some of the risk factors, however, are out of what high school trainers can provide, Fall said.

Pressure to play

As the intensity and competition have ramped up in prep sports, the demand to specialize in one sport has been on the rise. But critics say pressures for young athletes to devote all attention to a single sport is resulting in more injuries and little rest for those who train and play year-round.

According to a 2016 University of Wisconsin School of Medicine and Public Health study, high school athletes specializing in one sport were twice as likely to report suffering a lower-extremity injury compared to their multi-sport counterparts.

The study, which surveyed about 1,500 students across the state's rural, urban and suburban populations, also found specialized athletes succumbed to 60 percent more lower-body injuries than multi-sport athletes.

Though a number of factors go into ACL tears, Dr. Tompkins said he believes athletes who play the same sport year-round don't always focus on training other parts of their bodies. Lack of an offseason could be causing them to overextend themselves, he said.

"They don't get the cross training and they don't get the rest," Tompkins said. "If they have anything about their mechanics that put them at risk for injury, the more exposure they have, the more chances there are to have an injury."

Colleges are recruiting players at younger ages than in past years — in some cases athletes as young as 13 or 14 years old. But the chances of them playing for top schools are slim.

According to the National Collegiate Athletic Association, only 2.4 percent and 1.2 percent of high school girls, respectively, went on to play Division I soccer and basketball. The association estimates that about 15 percent of college basketball players go on to play professionally.

Shannon Rainey, a track and field coach and athletic trainer at East Ridge High School in Woodbury, said he faults sports specialization for driving overuse and ACL injuries.

Club sports leagues operating outside of high schools sometimes ask players to sign a contract promising to not play other sports. The practice that has fallen under criticism among athletic trainers and health professionals and has led to calls for cultural reforms in youth sports.

"They're so beat up that they're not even the same athlete I remember from their freshman year," Rainey said. "You can train hard and smart, but you have to do it the right way."

He and other trainers said they've been emphasizing the value of playing multiple sports.

Mike Carli, a father of a basketball player in Hudson, said he's felt indirect pressures to sign his daughter up for year round leagues out of fear coaches won't take her as seriously.

"If you don't do everything, sometimes it's kind of looked down on," he said.

Still, some players say the extra work is worth it if it leads to a scholarship at a top program or college.

"That's why everyone's doing all this extra training and trying to be on the best team and trying to get seen across the country and make a name for themselves," Hewitt said.

When asked if that was also her hopes while playing for Woodbury High School and teams outside of the school, she quickly responded, "yes."

Risk of re-injury

Though various high schools take precautions for players, girls who suffer an ACL injury are at a higher risk of re-damaging their knee, as well as the opposite, healthy knee, a fact Christie Carli knows all too well.

A 2017 Hudson High School graduate, she first tore her ACL weeks before the start of her junior year during a heated game in Woodbury.

With seconds left in the game and her team down by a point, she tried blocking a shot hoping to free the ball and pull off a miracle play. But as she came down from the air she collided into a bleacher near the sideline.

As the buzzer sounded, she crumbled to the ground as a pain rang in her right knee.

"It was like a sharp, twisting pain," she said. "It hurt."

Carli saw a rehabilitation specialist and said she took the program seriously while thinking she still had her senior season to play.

A year later, she scored 20 points in her first game back. Her coaches noticed she had regained her speed that she lost while injured.

But during an evening pickup game at a local gym last fall, her knee buckled while cutting to the basket and stumbling over another player's foot.

She felt a familiar pain. This time, in her left knee.

"I was crying, and it wasn't all because of the pain," Carli said. "It was because I knew it felt how it did the last time it happened."

Her younger sister called their father, fearing Carli had torn her ACL again.

"Dad, I think it happened again," Mike Carli recalled her telling him over the phone.

When he arrived at the gym, he said the coaches looked at him like ghosts. "They were fighting tears, Christie was in tears," he said. "It was very emotional."

Carli said the second injury came as a surprise. She eased back into playing after her first injury. Her team had also been doing ACL prevention workouts, and she was able to return to form in about a year. "I felt I was doing everything right," she said. "I didn't think it would happen to me."

Lengthy recoveries can be dispiriting

The process of returning from an ACL surgery can take anywhere between eight months to a year before an athlete is able to play again. And even then, there's no guarantee they'll be able to return to their former level of play.

The reconstruction surgery involves taking a small piece of muscle tendon and using it to replace the torn ACL.

The operation often saps a person's ability to bend the knee fully and requires them to sometimes wear a large brace that extends from the shin to the lower thigh as they rebuild lost strength.

Players say the lengthy recovery and the sudden inability to play can lead to a loss of identity.

"I went through this phase when I was just depressed," Carli said. "I was really losing spirit in myself."

She said her family, coaches and teammates helped support her as she sat bench-side watching her teammates for her last two years of high school.

Hewitt said the first four months were the hardest for her.

She recalled waking up at 5 a.m. to do two hours of physical therapy before going to school. When she came home, she did two more hours of physical therapy and then went to help out her coaches before returning back home to do homework and sleep.

While out for the year, Hewitt said she found a new role on her teams, acting in many ways as her coaches' assistant and working with her teammates.

After six months of rehab, her doctors allowed her to begin running again, and she started to see progress.

Carli said she's now able to play but has noticed the same decline in her speed that she experienced when tore her ACL the first time. Though she said she's focused heavily on strength training this time around, she still feels a slight hesitation when she plays.

Dr. Jack Skendzel, a surgeon at Summit Orthopedics in Woodbury, said much of the recovery process can be mental.

"It's called Kinesiophobia," he said, the fear of re-injury. "Oftentimes, what we see is the biggest factor in holding them back isn't anatomical or physical."

Skendzel said the anxiety is normal but can lead to hesitations that players aren't always to able to overcome.

Skipping surgery

Forgoing or delaying surgery on an ACL can be risky and can lead to several negative outcomes for athletes.

When torn, the lost stability the ACL provides wears down of the meniscus — a rubbery C-shaped disc that cushions the knee — as well as other major knee ligaments.

Prolonged damage caused by untreated injuries can lead to things like chronic pain and diminished mobility.

"There may not be much we can do to salvage at that point," Skendzel said. "It may be that you have permanent deficits, and we really can't reverse some of those changes anymore."

In a number of cases, especially in young people, surgery is often undergone shortly after a diagnosis.

According to Pediatrics, 70 percent of those surveyed underwent surgical ACL repairs in 2014, compared to 57 percent in 1994.

The first doctor Carli saw suggested she go home and ice her knee after not noticing anything amiss on her X-ray. A second opinion confirmed she had suffered a tear.

Though diagnosing the injury has improved, some athletes don't always know they're injured.

For more than a year Monica Monson, a teammate of Carli's, played sports on a torn ACL.

She said on several occasions she went to talk to trainers about problems with her knee swelling and was told to rehab and ice it. Within a few days, Monson said her knee seemed fine.

"No one actually considered it was that serious," she said. "The frustrating part was not knowing for a year and a half, and I didn't know what was wrong with my knee. Everyone just said it would go away."

Unlike sudden ACL tears, her knee looked normal. She later found a small tear had been worsening over time, resulting in a small tear in her meniscus as well.

Monson ultimately decided to have her ACL repaired even though she said she had been performing fine without it.

She said her recovery went well, and she played basketball and ran track her senior year. Monson said she plans to continue track while attending the College of St. Benedict in the fall.

Hewitt received a sports scholarship to attend South Dakota State University. She also tallied a goal and two assists after playing 75 minutes in her first game back from injury.

Despite not playing for two years, Carli still received attention from colleges and plans to play for St. Catherine University in St. Paul. Now with two "rock solid" knees, she's started playing a few days each week with the college.

"She never gave up, and I think that's the important part," Mike Carli said. "There were girls that could play and quit, but Christie never quit."